Non-suicidal self-injury

1. Non-suicidal self-injury Dr Claire Kelly Mental Health First Aid Training and Research Program ORYGEN Research Centre

2. Overview • What is NSSI? • Types of NSSI • Terminology • Why do people engage in NSSI? • Motivations • Outcomes • Controversies • Stigma

3. Overview • Associated mental disorders • Treatment • What do you do if someone has injured themselves? • Guidelines for first aid for NSSI • ALGEE • …Questions?

4. What is NSSI? • 3 main types of NSSI: • Major self-injury or major self-mutilation • Usually a result of psychosis • Single large injury (removing an eye, self-castration or cutting off a digit or limb) • Stereotypic self-injury • Usually associated with intellectual disability or brain injury, occasionally Autism • Repeated self-injury such as banging a head on the wall or self-punching over and over again

5. What is NSSI? 3. Compulsive self-injury • Usually associated with personality disorders and depressive disorders • Can be a pattern over weeks, months or years • This is the type of injury we are talking about.

6. What is NSSI? • Types of self-injury: • Cutting, scratching, ripping, tearing, burning, or pinching skin • Carving words or patterns into skin • Interfering with healing of wounds • Banging or punching objects or self • Self-poisoning when this is NOT intended to be a suicide attempt

7. Terminology • Non-suicidal self-injury • Deliberately inflicting physical harm on oneself without conscious intent to die. • Use a term which best reflects what you intend to say.

8. Who engages in NSSI? • Estimates vary: • 4% in general population (lifetime) • 7 - 21% in clinical populations (review) • 60% in psychiatric inpatients (review) • 13% - 23% of children and adolescents (lifetime) based on reviews • 3-47% in previous 12 months based on multiple cross-sectional studies • Exact numbers hard to estimate • Lets say “a lot”.

9. Motivations for self-injury • To escape from an intolerable state • Emotional pain, numbness • Suicidal feelings  Wanting to change others’ behaviours • Can be a morbid form of help-seeking • Can be a way to get noticed

10. Motivations • Feeling unreal or non-human • Seeing blood or feeling pain can stop this • Feeling dissociated • Can bring self back ‘into the body’ • “It should show on the outside” • Scars, wounds and dressings can express emotional pain and suffering • Showing desperation to others • To die* - not addressed here.

11. Outcomes • Common theme: • Current state is intolerable • SI can change the state enough to make it tolerable • Most people stop when they have what they need • Some can lose control • Most injuries are superficial • Can accidentally cause more serious damage or die

12. Controversies • A history of NSSI is associated with increased suicide risk • Relationship is very strong – but poorly understood • Some people argue that there is always suicidal ideation - even if person is not aware of it • Others argue that the person’s intent should be accepted as spoken • NSSI must be taken seriously, as a future suicide is possible.

13. Stigma • Individuals presenting to emergency rooms may be treated badly • Stigma towards people with borderline personality disorder can be directed toward people who have self-injured • NSSI is frightening to people who see it, is usually ugly, can leave visible scars and can provoke disgust

14. Associated mental illnesses • Most commonly associated with borderline personality disorder (BPD) • Also associated with depressive disorders, anxiety disorders, eating disorders, and others

15. Treatment • Treating any underlying mental illnesses can decrease number and severity of SI episodes • Small trials and small numbers mean there is little strong evidence for any specific treatments for SI alone • Some people describe a spontaneous remission in the urge to self-injure

16. First aid for NSSI • Evidence base is very limited • No evidence base for first aid strategies • Guidelines developed by the team • Consensus method • Consumers and clinicians • Guidelines document provided

17. The MHFA Action Plan: 1. Assess the risk of suicide or harm

18. The MHFA Action Plan: 1. Assess the risk of suicide or harm • Risks associated with SI: • Accidental death • Overdose or arterial bleeding • Permanent damage to muscles/tendons • Resulting in limited mobility • Secondary harms from infection

19. The MHFA Action Plan: 1. Assess the risk of suicide or harm • Attend to any serious injuries first. • Heavy bleeding, arterial bleeding • Burns (especially to face, hands and feet) • Possible broken bones • If you are able to offer first aid, do so. • Call for emergency assistance as needed. • If the person has taken an overdose, regardless of their intention, call an ambulance.

20. The MHFA Action Plan: 1. Assess the risk of suicide or harm • Offer to attend to less serious injuries. • Ensure adequate first aid supplies are available. • Be aware that tending to injuries may be part of what the person needs to do for themselves.

21. The MHFA Action Plan: 1. Assess the risk of suicide or harm • ASK: “Are you having thoughts of suicide?” • If YES: • Apply first aid for suicidal thoughts. • If NO: • Move on to the next action.

22. The MHFA Action Plan: 2. Listen non-judgementally • Always stay calm and do not express judgement • Do not express disgust or horror • Do not trivialise the feelings which have lead to the NSSI • Do not punish the person • Especially by threatening to withdraw care

23. The MHFA Action Plan: 2. Listen non-judgementally • If you suspect NSSI: • Don’t ignore signs - ask the person about what is happening. • Before talking to the person, consider your own state of mind: • Can you stay calm? • Can you help without saying something which may cause further hurt? • Can you cope with the person’s answer? • Ask the person if you can help them to feel better

24. The MHFA Action Plan: 2. Listen non-judgementally • If NSSI is confirmed: • Discuss SI calmly with the person • Remember that “stopping self-injury” is not the main aim • Main aim is to alleviate distress

25. The MHFA Action Plan: 3. Give reassurance and information • NSSI is a response to an intolerable emotional state • It is common • By getting help for the underlying problems, you can cope without it.

26. The MHFA Action Plan: 4. Encourage professional help-seeking • Self-injury is not an illness in itself • May need treatment for psychological distress or a mental illness • Make sure they know where they can get help, but don't force them to use it • A GP, psychiatrist or psychologist can help

27. The MHFA Action Plan: 5. Encourage self-help strategies • Talk to someone next time the urge hits • Develop your own methods for staying safe • Harm minimisation: • Ensure the person has adequate first aid supplies • This can reduce the risk of secondary harms from infections, etc.

28. Keeping safe • Ensure that the person has access to first aid supplies • Encourage them to speak to someone they trust next time they feel the need to injure themselves • Encourage them to find other ways to relieve pain • Encourage them to delay for as long as they can • Encourage them to do something distracting

29. Questions?